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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Conservative Access
The opinions within this web page are not ours.Authors have been credited
for the individual posts where they are. - photographs courtesy: Venkat, Marino
From: Venkat
Sent: Sunday, August 10, 2008 3:41 PM
Subject: [roots] [Roots] Conservative Access

Pt wanted to save the crown if possible. It is an all ceramic 
crown and I could access with minimal damage to the crown. I need 
to ensure that I clean the complete chamber space, hoping my irrigant
would get there. Is my approach justified? - Venkat

Venkat, All in the spirit of learning. It is difficult for me to tell...but I'm presuming this is a lingual access. It doesn't matter that much, as the points all apply: The key ferrule on these teeth is B and L. There is little quality L ferrule because the finish line is so high. Much of what little L ferrule was present has been removed by this cervially placed access, and it was removed in the worst possible location...straight L at the finish line of the restoration. The tooth cannot be restored properly with a DT-light post either, because the entry into the canal system is not straight. Because you are working around this curvature, your instruments are going to preferentially remove even more of the L tooth structure. See your wire film. This angle of entry also predisposes to gouging up the buccal, resulting in further loss of key PCD and degrading the already precarious ferrule quality. The crown has been weakend in a key spot as well, and provided a nidus for crack initiation. Notice that I have not talked about the endo at all...yet... Endodontically, working around a curve is possible, but more difficult. It is justified if you can preserve key tooth structure without severely compromising the endodontic result... i.e. it is a tradeoff. The more important the tooth structure, the more of a struggle working around a curve or bad angles) I will deal with in trying to obtain my desired endodontic result. In this case, key tooth structure was removed and in the process, resulted in an endodontic acces that hampers the endodontic result. In other words, your case is bascially the opposite of what I would do. Endodontists mistakenly get caught up in (falsely) believing that the endodontic result hasta be perfect. doesn't. It never is even close to perfect. Not even remotely. Not even in Marga's or Terry's hands. The endodontic result does not hafta be hasta be "good enough" To use Buchanan's words: "Perfectly Adequate" This is a huge advantage in a multiple visit approach to more complicated case types, in that the endodontic result can be monitored for "good enoughness" before proceeding to the restorative phase. In endodontic shaping, less is more. If I could obturate an un-access, unshaped case, I would. I aspire to be a "Perfectly Adequate" endodontist. The title of your post is what caught my attention: "Conservative Access" What exactly are you conserving? - John A Khademi Hi, IT IS NOT JUSTIFIED we must not omit a single step without compromising the entire care(Levin) the correct detersion is the combination between the correct instrumentation and the chemical action of the detergents all the moments of the endodontic treatment have to be of high quality - Marino Fine. Then, we will just have to remove the tooth because the patient cannot afford a new crown. That way, Dr. Borelli, you can be sure that you have not compromised on any aspect of treatment. You won't have many patients, mind you. But your integrity will remain intact and that seems more important to you. I hope that helps you pay your staff at the end of the day but I have the feeling that they would prefer a paycheck rather than the satisfaction in knowing that YOU retained your principles by demanding that the crown be removed in every case. It IS possible to treat these teeth with conservative access (assuming the crown is acceptable to you) - without compromising the case. If you don't know how, you should learn to do this. It is ALWAYS easier to do it exactly as the book says because it takes no improvisation. Just follow the directions like a cook book. Unfortunately, we are dealing with human beings rather than inanimate objects. You need to be somewhat flexible. People DON'T have unlimited finances or patience. The key to managing such cases is deciding (with experience) how far you can push the envelope and still achieve a relatively predictable result. Dogma works well in textbooks and discussions like this....but rarely in the real world. Perhaps you should ask Venkat what the fee is for the endo retreat or for a new crown ...then compare it to yours. It may surprise you. - RobK Dear Dr. Rob Kaufman, If the access is wrong, you can loose the crown and the tooth. when the tooth is necrosis a more great access allows you to save everything. Often,the patients asked to save the crown and I tried to do it. But I operate on the crown as a normal tooth. I did not say to remove the crown, I said to open more the access to give more certainty to the patient and me. the patient asks the healing of disease and save the crown, what does the treatment if I have many doubts healing? I am very surprised Dr. Rob Kaufman - Marino I agree with Dr. Mariano Borelli. - Jose Claudio Provenzano Let me step in here to defend Dr Kaufman. He has unequivocally stated on his web pages about the futility of trying to save a crown and ending up compromising the endo and the future of the tooth. He has clearly mentioned so in as many words. What he has said on this chat is that there are times that 1) the patient is adamant about not loosing the crown 2) you have alternate ways to access the root 3) the patient is willing to accept responsibility for any type of failures. No endodontist EVER wants to preserve the patient's artificial crown. What he means that in the real world one may have to work under constraints and the referror and the patient may not be amused at your suggestions of a New crown after endo. He is talking about alternative possibilities in the event when the endodontist may be FORCED to compromise and soften his stand, after all how many patients can he refuse to treat. Dr Kauffman and Dr Venkat aren't recommending conserving artificial crowns. They are talking about the event when your back is against the wall. - Dr Sanjay Jamdade HI Dr Sanjay Jamdade Probably I was not clear. Many times in my life (Endodontist by 27 years) I have dealt crowns that the patient did not want to change, I have always tried to respect the will of the patient, but I have dealt with the crown as if it were natural tooth.. I want to say that The crown can be saved with access that allows you to bring the instruments in the channel without obstacles, the problem is not the crown. A small access certainly does not allow the endodontic treatment and the disease's tooth, probable, will continue to give discomfort to the patient. The debate is not between those who decide to negotiate and those who refuse to treat, the debate is between a proper access and an incorrect access, not between the utility or the uselessness to leave the crown. - Marino Case 1: The patient woman of 50 years did not wish to change the crowns on 15 and 16 Case completed and recall to 6 years

Case 2: the patient was advised to change all the bridge but she did not accept. Case completed in the first week of current month.

OK - Dr Sanjay Jamdade Very nice work Marino! What is your method of obturation? - Andreea My method of filling is the condensation of gutta-percha heated in the channel. thank's for compliments - Marino I got it: downpack with a heated plugger up to 4 mm from WL and condensed with a cold plugger that can reach up to 2 mm from WL. Then the backfill with an Obtura gun? And what is the usual distance from WL that you usually fit your mastercones? - Andreea Hi Venkat, I would be reluctant to say one approach is never justified, however the two concerns I would have would be leaving incisal tissue behind, and also since approx 40% of these will have a facial and lingual canal, that the angle of entry would not allow you to negotiate the lingual portion, or make it very difficult, even using precurved instruments. Also leaving tissue behind may darken the crown, and if this is a translucent porcelain....may darken later. Here is a recent case where I went through the veneer with a needle diamond. Right through the incisal edge. Then used a glass fiber post, with buildit to restore. Sorry no clinical pic... "More than one way to skin a kitty" - Tony Tony my man! Stone-cold-dead-on-perfect! - John A Khademy is not a scientific fact, but what happens in the channel. Mastercone to 0.5 mm from LL, heat carrier to 4 mm from LL, plugger to 2 mm from LL. the last 0.5 mm channel are discovered for consumption with bur. gp is pushed by the plugger (looks to two mm, we see the thrust of plugger)goes to exactly fill the empty space. the backfill with Pac Mac. compared to the technique of classical compaction , change the mode of administration of heat and the use of plugger constructed with metal ductile and flexible - Marino

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